Acceptance and Commitment Therapy: End state functioningDr Matthew SmoutCentre for Treatment of Anxiety and DepressionSouth Australia

Aims

Overview how healthy ACT recipients are at the end of treatment

Put this in the context of end-state functioning typically achieved by other CBTs

Bench-markingTypical use: Once efficacy established in tightly controlled

RCTs Evaluation of an EBT in “real-world” community

setting (some inclusion criteria relaxed) Model RCTs are selected either individually or

aggregated to serve as benchmark Comparison informal

Clinical significance End-state functioning measured by clinical significance

Jacobson & Truax (1991) criteria: > 2 SDs improvement on pre-test mean < 2 SDs of functional population post-test Post-test closer to functional than dysfunctional mean

Pre-determined reduction in Sx (e.g., 50%) Composite or selection of outcome measures

Even large effect sizes are not necessarily clinically significant

16/62 ACT RCTs included this information (Smout et al., 2012)

A further 3 ACT non-RCTs provided info (Scopus search on ACT in Title, 1/6/13).

OCD Studies

0

5

10

15

20

25

30

35

40

Foa et al(2005)

vanOppen et

al(1995a)

Lindsayet al

(1997)

Cottrauxet al

(2001)

McLeanet al

(2001)

Franklinet al

(2000)

Tw ohiget al

(2010)

Study

Y-B

OC

S

Pre YBOCS M

Post YBOCS M

Non-clinical

“recovered”

Error bars = 1 SD

OCD Studies: RCI analysis

0%10%20%30%40%50%60%70%80%90%

100%

Foa et al(2005)

vanOppen et

al(1995a)

Lindsayet al

(1997)

Cottrauxet al

(2001)

McLeanet al

(2001)

Franklinet al

(2000)

Tw ohig etal (2010)

Study

Perc

enta

ges

Reliably Improved

Recovered

Study/

Variable

Foa et al (2005)

Van Oppen et

al (1995a)

Lindsay et al

(1997)

Cottraux et al

(2001)

McLean et al

(2001)

Franklin et al

(2000)

Twohig et al

(2010)

Female 62% 52% 44% 64% 48% 47% 61%

Age 33.8(8.9) 35.3(10.1) 31.6(8.9) 34.8(11.4) 35 34.2(13.1) 37(15.5)

Married/

Cohabitating

28% 38% 44% NR NR 31% 33%

Education NR 31% low

24% hi

22% low

45% hi

NR 5% low, 73% hi

46% uni M=14.9

(2.0) yrs

Employed NR NR NR NR NR 39% NR

Duration 14.4(11.5) 14.4(11.7) 9.0(8.7) 11.4(8.7) NR NR 20.5(17.1)

Using Medication

No No 27% ?Hypnotics 63% 60% 40%

Comorbid Axis I

NR NR NR 31.2% 50% 54% 51%

Comorbid Axis II

NR NR NR 34% OCPD

NR 17% NR

OCD study sample characteristics

Social Phobia studies using SPAI

0

20

40

60

80

100

120

140

160

180

Clark et al(2006)

Gruber(2001)

Newman(1994)

Stangier(2003)

Turner(1994)

Dalrymple& Herbert

(2007)

Ossmanet al

(2006)

Study

SP

AI (

0-19

2)

Pre

Post

CT CBT EX EXCT

ACT ACT

ACT studies

Study/

Variable

Clark et al (2006)

Gruber et al (2001)

Newman et al

(1994)

Stangier et al

(2003)

Turner et al

(1994)

Ossman et al

(2006)

Dalrymple & Herbert

(2007)

Female 44% 52% 50% 49% 61% 50% 53%

Age 31.95(8.6) 41.7(8.2) 46.57(9.4) 38.8(10.5) 35.4 42.4 31(10)

Married/

Cohabitating

36% NR NR NR NR NR < 19%

Education 59% > HS

31% < HS

NR NR 32% > HS

66% < HS

NR NR 89% > HS

Employed 81% NR NR NR NR NR 54%

Duration 13.13(11.15)

NR NR 56% > 15y

19.2 38.7 NR

Using Medication

28% 16% Excluded 6% 0% NR 16%

Comorbid Axis I

21% current

NR NR 75% NR NR 48.6%

Comorbid Axis II

56% NR NR 35% NR NR 59.5%

Social phobia study sample characteristicsACT studies

ACT for GAD benchmarking CBT: PSWQ

01020304050607080

Roemer et (2008) Arch et (2012) Wetherall et (2011) CBT aggregated

Study

PSW

Q (1

6-80

)

Pre

Post

• Arch study: only 25% sample primary GAD

• Error bars = SD

Benchmarking ACT for GAD against CBT: PSWQ Reliable change

0

20

40

60

80

100

Arch et (2012) Roemer et (2008) Wetherall et(2011)

Weighted averageCBT

Study

%

Reliably Improved

Recovered

Demographics of ACT studies v CBT benchmarks depression

Study/

Variable

Unweighted CBT

average

Zettle & Rains (1989)

Forman et al

(2007)

Forman et al (2012)

Peterson & Zettle (2009)

Folke et al (2012)

Female 69% (14.3) 100% 76% 79.5%* 42% 94.4%

Age 43.8 yrs (12.1)

41.3* 27.9* 26.7 (6.4)* 36.7 (11.5)

40.6 yrs (10.14)

Married/

Cohabitating

53.8% (23.5)

NR 34.7%* 49.3%* 8.3% 83.3%

Education 13.5 yrs (1.3)

14.1yrs* NR NR 11.9 yrs (2.7)

NR

Employed 53.4% (28.8)

NR NR NR NR 0%

Duration 8.8 yrs (5.6) NR NR NR NR NR

Using Medication

38.3% (21.7)

NR NR 16.7%* NR 77.8%

Comorbid Axis I

28.4% (16.1)

NR NR NB: 34.8% DD

NR NR

Comorbid Axis II

37.5% (25) NR NR NR NR NR

ACT for depression studies pre-post benchmarked against CBT: BDI

0

5

10

15

20

25

30

35

Zettle &Rains(1989):

Forman et(2007)

Forman et(2012)

Peterson &Zettle (2009)

Folke et al(2012)

WeightedaverageCBT:

Study

BD

I (0

-63)

Pre

Post

• CBT studies from Thoma et al (2012) meta-regression where trial quality score > 24 (55 Tx arms in 33 studies)

• error bars: SEM

Severe

Recovered

ACT studies

ACT for depression in adults: benchmarked against CBT reliable change analysis self-report

0%

10%

20%

30%

40%

50%

60%

70%

Fledderuset al

(2011)Max Email

+ SH

Fledderuset al

(2011)Min Email

+ SH

Forman et(2007)

Forman et(2012)

Zettle &Rains(1989)

Folke et(2012)

CBTweightedaverage

Study

Pe

rce

nta

ge

(0

-10

0%

)

reliably improved

recovered

ACT for depression effect sizes benchmarked: BDI

0

0.5

1

1.5

2

2.5

TreatmentEfficacy ITT

TreatmentEfficacy

Completers

NaturalHistory

Zettle &Rains

(1989) CD

Forman et al(2007)

Forman et al(2012)

Peterson &Zettle(2009)

Folke et al(2012)

Study

Co

hen

's d

Aggregated benchmarks calculated by Minami et al (2007)

Efficacy > RCT benchmarks

NB: Below lower red dotted line: No better than natural remission

Aggregated benchmarks calculated by Minami et al (2007)

NB: Below lower red dotted line: No better than natural remission

ACT for depression effect sizes benchmarked: HRSD

0

0.5

1

1.5

2

2.5

3

TreatmentEfficacy ITT

TreatmentEfficacy

Completers

Natural History Zettle & Rains(1989) CD

Peterson &Zettle (2009)

Study

Eff

ect

size

(C

oh

en's

d) Efficacy > RCT benchmarks

ACT for pain: pain intensity effect sizes benchmarked

00.10.20.30.40.50.60.70.8

Ersek

(2008

)

Spinho

ven (2

004)

Leeu

w (200

8) E

XP

Leeu

w (200

8) G

A

Schm

idt (2

011)

Jens

en (2

001)

male

s

Jens

en (2

001)

fem

ales

Wick

sell (

2008

)

Wethe

rall (

2011)

Thors

ell (20

11)

John

ston

(201

0)

Mo't

amedi

(201

2)

Dahl (2

004)

Eff

ect

size

(C

oh

en's

d)

ACT studies

Demographics of ACT studies v CBT benchmarks pain

Study/

Variable

Ersek et (2008)

Spinhoven (2004)

Leeuw (2008)

Schmidt (2011)

Jensen (2001)

Wetherall (2011)

Female 87.2% 64% 48.2% 100% 45% 50.9%

Age 81.9 39.8 45.3 53.4 43.8 54.9

Married/

Cohabitating

< 25% 80% NR 52.8% 74% 43.9%

Education 71% > 12 78% < 10 43.5% lo

44.7% mid

21% hi

42% mid

17% > 12

60% < 12

44.7% > 15

Employed NR 79% disability

comp

36% emp

26% DSP

36% emp

38% retire

86% emp 29.8% emp

47.4% DSP

Duration NR 9.8 9.0 14.5 1.8 15.0

Using Medication

NR NR 72% NR NR 95.6%

Main Pain sites

Legs, back, hips/buttock

Lower back Lower back

Fibro- myalgia

Spinal pain

Lower extremity,

lower back, upper ext

n 114 130 42 53 49 57

ACT study

Demographics of ACT studies v CBT benchmarks pain

Study/

Variable

Ersek et (2008)

Spinhoven (2004)

Leeuw (2008)

Schmidt (2011)

Jensen (2001)

Thorsell et (2011)

Female 87.2% 64% 48.2% 100% 45% 64.4%

Age 81.9 39.8 45.3 53.4 43.8 46

Married/

Cohabitating

< 25% 80% NR 52.8% 74% 64.4%

Education 71% > 12 78% < 10 43.5% lo

44.7% mid

21% hi

42% mid

17% > 12

60% < 12

NR

Employed NR 79% disability

comp

36% emp

26% DSP

36% emp

38% retire

86% emp 22% emp

62.2% S/L

Duration NR 9.8 9.0 14.5 1.8 NR

Using Medication

NR NR 72% NR NR NR

Main Pain sites

Legs, back, hips/buttock

Lower back Lower back

Fibro- myalgia

Spinal pain

NR

n 114 130 42 53 49 12

ACT study

Demographics of ACT studies v CBT benchmarks pain

Study/

Variable

Ersek et (2008)

Spinhoven (2004)

Leeuw (2008)

Schmidt (2011)

Jensen (2001)

Wicksell et (2008)

Female 87.2% 64% 48.2% 100% 45% 82%

Age 81.9 39.8 45.3 53.4 43.8 48.2

Married/

Cohabitating

< 25% 80% NR 52.8% 74% 64%

Education 71% > 12 78% < 10 43.5% lo

44.7% mid

21% hi

42% mid

17% > 12

60% < 12

NR

Employed NR 79% disability

comp

36% emp

26% DSP

36% emp

38% retire

86% emp 27% emp

Duration NR 9.8 9.0 14.5 1.8 7.0

Using Medication

NR NR 72% NR NR NR

Main Pain sites

Legs, back, hips/buttock

Lower back Lower back

Fibro- myalgia

Spinal pain

Neck

n 114 130 42 53 49 11

ACT study

Pain disability: Reliable Improvement

0

5

10

15

20

25

30

35

40

45

50

ACT Other psychotherapy

Wei

gh

ted

ave

rag

e %

ACT studies: McCracken et al (2007); Vowles et al (2008)

Other: 8 Tx groups from 4 studies (Leuw et al, 2008; Ersek et al., 2008; Smeets et al., 2008; Schmidt et al., 2011)

ACT pain studies: meta-prevalence of reliable and clinically significant change

0

20

40

60

Depression Pain anxiety

Parameter

Aver

age

wei

ghte

d %

Reliably Improved

Recovered

McCracken et al (2007); Vowles et al (2008); Johnston et al (2010)

ACT for psychosis in context

Rehospitalisation CBT Control

Drury (2000) - 4 yrs FU

1.2 (1.4) 1.2 (1.4) ns

Bechdolf (2005) – 2yrs FU

37.5% 59.3% ns

Buchkremer (1999) – 2yrs FU

38% 50% ns

Penn et (2009) – 1yr FU

18% 11% ns

Jackson et (2008) 40% 29.6% ns

Gaudiano & Herbert (2006)

ACT: 28% 45% ns

Bach et al (2012) – 1yr FU

ACT: 40% TAU: 80%

Study/

Variable

Buchkremer (1997)

Kemp (1998) Pinto (1999) Guadiano (2006)

Female 42% 48.7% 70% 36%

Age 31.3 34 33.9 40

Married/

Cohabitating

NR NR NR 12%

Education NR NR 9.2 17% > 12yrs

35% < 12yrs

Employed NR NR NR 13% employed

Accommodation NR NR NR 29% homeless

12% own home

Duration of illness 8.4 8.5 11.6 NR

Chlorpromazine eq 4639 NR 735 NR

Hospitalisations 4.7 4.4 4.3 NR

Psychosis study sample characteristicsACT studies

Error bars = SD

ACT for psychosis benchmarked against CBT: BPRS

18

38

58

78

98

118

Buchkremer (1997)[n=147]

Kemp (1998) [n=39] Pinto (1999) [n=19] Gaudiano (2006)[n=21]

Study

BPRS

(18-

126)

Pre

Post

Study/

Variable

White et (2011)

Shawyer et (2012)

Bechdolf et (2005)

Cather (2005)

Haddock (2009)

Valmaggia (2005)

Penn (2009)

Female 29% 29% 46% 25% 14% 23% 47%

Age 33.6 40 31.8 45.9 35.7 35.4 41.7

Married/

Cohabitating

7.1% NR 11.4% NR 3.9% 7% NR

Education 36% >12

36%<12

11.7 NR 13.1 NR 14% > 12

68% <12

12.8

Employed 0% 19% 13.6% NR NR 3% 50%

Accommodation NR 51% indep

44% indep

NR 5.2% indep

NR <31% indep

Duration of illness NR 14.2 NR 24.9 NR 10.4 14

Chlorpromazine eq

NR 742.9 NR 433 400-1000 NR NR

Hospitalisations NR NR NR NR NR 3.8 7.6

Psychosis study sample characteristicsACT studies

ACT studies Psychosis benchmarked against CBT: PANSS-P

79

1113151719212325

White et(2011)[n=14]

Shawyer et(2012)[n=18]

Bechdolf et(2005)[n=40]

Cather(2005)[n=15]

Haddock(2009)[n=77]

Valmaggia(2005)[n=35]

Penn (2009)[n=32]

PANS

S-Po

sitive

(7-49

)

Pre

Post

Error bars = SD

ACT studies Psychosis benchmarked against CBT: PANSS-N

79

1113151719212325

White et(2011)[n=14]

Shawyer et(2012)n=18]

Bechdolf et(2005)[n=40]

Cather(2005)[n=15]

Haddock(2009)[n=77]

Valmaggia(2005)[n=35]

Penn (2009)[n=32]

PANS

S-N

(7-4

9)

Pre

Post

Conclusions ACT for most conditions achieves outcomes

within the range of average CBT studies (neither exceptionally better not worse) ?exception of social phobia

Larger samples of ACT participants would be needed to have more confidence in the point prevalence estimates

ACT researchers could contribute to efficient bench-marking through consistent reporting of essential demographic information.